Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Claims processing requirements for PCPs rendering services to members in long-term care facilities

July 2, 2015

This is a reminder of the requirements for primary care physicians (PCP) when rendering services to members in long-term care (LTC) facilities. It is important to adhere to these requirements when providing such services or your claims may be denied. This information is documented in the Provider Manual for Participating Professional Providers and was previously published in Partners in Health UpdateSM.

Member must be on PCP?s LTC panel

Please note the following two requirements related to PCPs and their LTC panel:

  • PCPs who provide services to members in an LTC/custodial setting must have a separate LTC provider number established in our system. This separate provider number must be used when submitting claims for services rendered to members residing in an LTC facility (custodial members). If you do not have a separate LTC provider number and you are seeing Independence members residing in an LTC/custodial setting, please contact your Network Coordinator to establish an LTC provider number.
  • The members you provide care to in the LTC setting must be on your LTC panel or the claim will be denied. Please remind your Independence LTC patients who are not included on your panel that they, or their legal representative, need to contact Customer Service to select your LTC location. You may also want to consult with the administrative staff of the LTC facility to assist with educating the members and/or their legal representative of the need to be on the PCP?s LTC panel.

Note: Members who are on your office panel but now reside in an LTC facility must contact Customer Service in order to be moved to your LTC panel.

Referral requirements for members in LTC

PCPs with an LTC panel must issue a referral to an in-network provider for any professional service or consultation for an LTC-panel member in LTC. This requirement includes:

  • podiatry, physical therapy, and radiology services
  • consultation or follow-up with a specialist
  • ancillary services

Note: LTC-panel members do not have capitation requirements for laboratory, physical therapy, or radiology services. Also, the services listed above do not require precertification.

PCPs should submit referrals for LTC-panel members in advance of the service being provided. Referrals can be submitted by using the NaviNet® web portal, and they should be submitted in a timely manner to allow for appropriate claims processing. Claims will not be authorized for payment without a referral on file. In addition, consultants and ancillary providers are encouraged to provide the referral information with the claim to assist in processing.

Billing requirements for members in an LTC facility

Services for members in custodial care are to be billed with Place of Service code 32.

If you have any questions about LTC services, please contact your Network Coordinator.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.